Suicide is a growing problem in the world and is seen not only in general population but also among those who are behind bars. Custodial deaths have always been looked on by suspicion by the public at large. Death in custody could be by natural or unnatural means. It remains to be a very sensitive issue and at times difficult to understand. There are studies conducted in several parts of the world which have shown an increase in suicide in custody over the past five decades with prevalence rates also slightly higher than the general population.[1],[2],[3],[4] There is an article in this journal issue by Egziabher et al. which is looking at suicidal ideations and associated factors at a correctional center in Addis Ababa.[5] There is hardly any Indian data on this problem.[6] A monograph by the National Human Rights Commission (NHRC)[7] on suicide in prison was published in December 2014 after an incident of two suicides within 72 h in Tihar Central prison in March 2013 with one of them being the accused of the Delhi gang rape case. The NHRC then wanted to understand the factors leading to suicide in custody and frame a comprehensive plan to prevent such acts.

Suicide Death Rates in Indian Prisons

The available data about the prevalence of suicide in Indian prisons is variable, and from 1995 to 2014, 999 suicides were reported with 141 occurring in Tamil Nadu prisons. The prison data showed that approximately three inmates died daily on an average in Indian prisons and the number had increased to about five deaths/day in 2014. The cause for death would be natural, but at least two would be suicides. Although 90% of these deaths were recorded as natural, it still remains questionable as to what constitutes natural in a custodial setup.[8]

The NHRC monograph revealed 71% of the unnatural deaths in prison from 2007 to 2011 to be suicides. Furthermore, the average suicide rate among the general public for this period was 11/100,000 populations, whereas the average suicide rate in prison was 16.9/100,000 populations. The overall prison population in this period was 3, 76,000 with the overall average death rate being 375 and suicide rate being 16.9. This showed that the suicide rate in prisons was one and a half times more than the general population.[7]

Psychiatric Morbidity in Inmates

NHRC study suggested that the two primary causes for suicides in prisons included “the environment in the jail, which is apparently “conducive” to suicidal behavior, and the second is the” crisis situation faced by an inmate.”[7] Few Indian researchers have studied psychiatric morbidity in prisoners which could be one of the underlying causes for suicide. Kumar and Daria [9] in their study in central jail, Kota Rajasthan found the prevalence of psychiatric disorders to be 33%. Psychotic disorders in prisoners were 6.7% including 3.4% schizophrenia and 2.5% bipolar affective disorders. Neurotic disorders were seen in 26.3% of prisoners. Depressive disorder was seen in 16.1% of prisoners. Anxiety disorders were seen in 8.5% including generalized anxiety disorder and obsessive-compulsive disorder as 6% and 2.5%, respectively. The somatoform disorder was seen in 1.7% of prisoners. History of drug abuse or dependence before imprisonment was found in 58.8% of prisoners. The overall prevalence of psychiatric morbidity in general population in India has been reported in the range of 9.5–370/1000 population.[10]

A study looking at the profile of male forensic inpatients in South India with prisoners referred to psychiatric hospitals for diagnosis and treatment of behavioral problems such as violence and suicidality, substance use, certification, fitness to stand trial, assessment for the presence or absence of psychiatric illness, review of existing psychiatric medications, and insanity defence [11] found psychiatric diagnoses in 122 (90.3%) patients. The most common diagnoses were psychosis, including schizophrenia (28.2%), cannabis dependence syndrome (17.1%), depression (14.1%), adjustment disorder (11.1%), alcohol dependence syndrome (10.4%), and antisocial personality disorder (9.7%).[12]

Goyal et al.[13] in their study of 500 convicts in central jail Amritsar found psychopathology in 23.8% with depressive disorders in nearly 18% of the prisoners and schizophrenia seen in only two prisoners. Another 56.4% had substance use disorders as per the International Classification of Diseases 10 diagnostic criteria. Hence, their prevalence was significantly higher than that seen in general population.

Navpreet et al.[14] studied female prisoners in Patiala and found 61.5% of women inmates having psychopathology on General Health Questionnaire (GHQ)-12 with 33.8% having evidence of distress and another 27.7% having a severe problem and psychological distress on GHQ. On the other hand, a very low prevalence of 1% and less for depression and schizophrenia was found by Kumar et al.[15] in their study on the health status of prisoners in central jail of South India.

Risk Factors for Suicide in Prisoners

Individual factors

These include age, gender, type of custody, history of substance use, history of any psychiatric morbidity, or prior suicide attempts. It also includes coping of the inmate to the various stressors and presence of any coexisting medical illnesses.

Trial related factors

These include pretrial inmates and sentenced prisoners. Certain time periods were found to have a heightened risk for suicide, namely, first 24 h of confinement, intoxication/withdrawal, waiting for a trial, sentencing, impending release, change of cell, holidays, decreased staff supervision, etc.

A review by Gupta and Girdhar [6] on risk factors of suicide in prisoners revealed that in central jail Tihar which has an inmate capacity of 13,000 there was an increasing trend of completed suicides. In their analysis, data of 10 years, they found that those who committed suicide were males in the age range 22–28 years of age except for two inmates who were 18 years and 38 years of age, respectively. All committed suicide by hanging except one who died by strangulation. All were under trial detainees, and no one was sentenced. The probable reasons cited were ongoing stress related to court proceedings and anticipation of the unfavorable outcome of the trial.

The NHRC monograph [7] gave the characteristics of prison environments which were conducive to suicide. They are as follows:

Authoritarian environment: regimented experience

No control over future: feeling of hopelessness and helplessness in inmates

Isolation from family, friends, and society

Feelings of shame due to incarceration

Dehumanizing experience due to lack of privacy and overcrowding in prisons

Fears of the jail environment as often depicted in media

The insensitivity of prison staff to the feelings experienced by those who have been incarcerated whether guilty or not

Hostility and bullying by other inmates

Lack of medical facilities and no facilities for psychological counseling.

Delay in deciding parole.

The characteristics of the crisis situation leading to suicide are described as:

History of recent substance use

The recent loss of stabilizing resources such as loss of a spouse/loved one/home/finances

Guilt about the offense

History of being raped/assaulted

Presence of an underlying mental illness

Presence of an underlying physical illness

Difficulty in coping with the situation.

Legal Implications in Suicide in Custody

There have been several incidents of custodial death due to suicide, assault by inmates or medical negligence where the Hon'ble Supreme Court and the High Courts have held it to be the vicarious liability of the State as the inmates in prisons are under the care and protection of the State. It is the fundamental right of the inmate (right to life and personal liberty, Article 21) to be assured of security and protection in the jail environment. Hence, there is a great responsibility on the police and prison authorities that an inmate is not denied this right. The court has often ordered monetary compensation by the State to the near and dear ones of the person in cases of custodial deaths, but the State has the right to recover the amount from wrongdoers or delinquent officers responsible for negligence or commission of the act.

Preventive Measures for Custodial Deaths by Suicide

Provision to evaluate the mental health of prisoners at entry into prisons: identifying persons under intoxication, history of substance dependence, appropriate testing, and facilities for treatment of withdrawal

As per the WHO Mental Health Atlas More Details 2014,[16] the available mental health resources calculated per 100,000 population for our country is an abysmal 0.30 psychiatrists, 0.07 psychologists, 0.07 social workers, and 0.12 nurses. Hence, the appointment of mental health professionals which would include a psychiatrist, social worker or a psychologist and a counselor for every central prison would be difficult to achieve though it is a dire need

Having a suicide safe cell in the prison environment where inmates having suicidal risks or behaviors can be kept under observation

Reforms in prison administration.

The NHRC monograph has given several recommendations to reduce the risk and improve the assessment of those at risk for suicidal behaviors.[7] There also should be an allocation of funds for the mental health of the prisoners in the prison budget. It remains to be seen whether there is a change in “attitude” toward prisoners and reforms in administration help in improving the plight of our prisons.